Provider Demographics
NPI:1891019758
Name:RUSSELL, STEPHANIE N (FNP-BC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:N
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-8649
Mailing Address - Country:US
Mailing Address - Phone:937-286-4024
Mailing Address - Fax:
Practice Address - Street 1:3572 DAYTON XENIA RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-2886
Practice Address - Country:US
Practice Address - Phone:937-427-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-22
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA11080363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily